Der Weg regionärer Lymphbahnmetastasen bei Weichgewebssarkomen

Lymph node metastases originating from soft tissue sarcomas are very rare and the reason for this is unclear. While this observation was less important in former times when ultraradical excision and amputation were the norm, modern reconstructive surgical treatment options have to take the possibility of lymphatic metastases into account. We attempted to identify parameters that may be predictive of lymphatic metastases in a cohort of 1,597 patients with soft tissue sarcomas of whom 26 patients (1.6? %) had regional lymph node (RLN) metastases. We studied these RLN metastases with recently described techniques that enabled us to histologically visualize lymphatic vessels. We conclude that sarcomas should not be evaluated from a histogenetic perspective but more on the basis of regional topography of the lymphatic vasculature. As we described previously, two different lymphatic systems should be differentiated: lymphatic vessel system I (LGS I) contains RLN and lymph vessels are mostly superficial; however, there are also vessels near large blood vessels of the extremities. System LGS II is more delicate and its vessels run into the musculature, a metastatic homing area of many sarcomas. Lymph vessels of system LGS II drain directly into veins without intervening lymph nodes. Sarcomas with LGS I drainage will form RLN metastases. In contrast, sarcomas with LGS II drainage will do so only after surgical resection if system LGS I has been opened.     

Bandnaht und/oder Kapsulodese bei skapholunärer Instabilität

We have reviewed 37 patients with scapholunate instability, operated in Paris between 1979 and 1995 7 months after the injury. There were 12 partial and 18 complete ligament ruptures, but also 4 distensions. The repair was a secondary suture in 16 cases (7 direct, 1 transosseous, 1 combined, 5 anchor, 2 transosseous with anchor). A capsulodesis was performed 7 times as an isolated and 8 times as a combined procedure. 6 previous cases have been treated by ligamentoplasty. We present the results after a mean postoperative follow-up of 27 months, with good results on pain and grip, maintaining a satisfactory range of motion.     

Ergebnisse bei der Versorgung per- und subtrochantärer Femurfrakturen

Background

Can the helical blade in proximal femur nailing antirotation (PFNA) reach a better bony fixation than proximal femur nailing (PFN), thereby decreasing complication rates and improving clinical outcomes especially in osteoporotic bone?

Materials and methods

In a retrospective study complications and clinical treatment results of pertrochanteric and subtrochanteric femoral fractures were analyzed. For this purpose a group of patients stabilized with PFN (n=65) were compared to a patient group treated with PFNA (n=66). Objective and subjective parameters were acquired and analyzed by clinical follow-up studies using the Merle d’Aubigné score and X-ray evaluation. Individual bone quality was analyzed radiologically by determining the Singh index. The mean follow-up time was 7 months in each group.

Results

The PFNA showed a decrease in postoperative implant-associated complications especially in osteoporotic bone and unstable fracture types.

Conclusion

The philosophy of the PFNA blade with better fixation through an increased implant-bone-interface and smaller cross-section, compaction of cancellous bone as well as an antirotational fixation, seems to show advantages compared to the double screw system of the PFN.     

Minimalinvasive Chirurgie primärer und sekundärer Lebertumoren

Background

Initially, mainly superficial liver lesions were resected laparoscopically but now even major resections are performed using a minimally invasive procedure. Careful selection of suitable patients is of key importance.

Aims and methods

This article describes the current state of the art in patient selection and choice of the appropriate laparoscopic technique based on a review of the recent literature. Perioperative and oncological outcome parameters of laparoscopic liver resection are presented.

Results

Laparoscopic liver resection offers significant benefits compared to open liver resection in terms of reduced intraoperative blood loss, reduced overall and liver-specific complications and length of hospital stay without compromising oncological outcomes.

Conclusion

Lesions in the peripheral anterolateral segments (segments 2, 3, 4b, 5 and 6) are particularly suitable for laparoscopic liver resection. Access to the posterosuperior segments 1, 4a, 7 and 8 is more challenging but safe and feasible in experienced centers.     

28. Primärer und sekundärer Hyperparathyreoidismus

Zusammenfassung Beim primären, autonomen Hyperparathyreoidismus führt die Parathormon (PTH)-Überproduktion zu Symptomen am Skelet und (infolge Hypercalciämie) an Nieren, intestinalen Organen, Zentralnervensystem u. a. Beim sekundären Hyperparathyreoidismus werden die Nebenschilddrüsen durch chronische Hypocalciämie (bei Niereninsuffizienz infolge Phosphatstau und Störung des Vitamin D-Stoffwechsels) stimuliert, Behandlungsbedürftigkeit ergibt sich bei Skeletschäden. Für die Diagnostik stehen Calcium-, PTH- u. a. blutchemische Bestimmungsmethoden zur Verfügung, sie werden ergänzt durch Röntgenologie und Knochenhistologie.Mit Unterstützung der Deutschen Forschungsgemeinschaft, SFB 87 Endokrinologie, Ulm     

Arthroskopische Arthrolyse bei primärer oder sekundärer Schultersteife

Objective of endoscopic arthrolysis of the shoulder is the restoration of joint mobility in the primarily or secondarily stiff shoulder. The indication is given in primary and idiopathic adhesive capsulitis and in secondary, posttraumatic contracture of the shoulder with intolerable complaints and a loss of function over 6 months despite conservative treatment. Relative contraindications are a frozen shoulder in its initial inflammatory stage and posttraumatic stiffness with incongruency of the joint. The operation is performed using an arthroscopic technique with three standard portals. After partial synovectomy, the capsule is incised mechanically or electrically, and optionally a capsule strip can be resected. Subsequently, paraarticular and subacromial debridement is performed. Postoperative physiotherapy is crucial and is complemented by a continuous passive motion splint. Arthroscopic arthrolysis can accelerate the spontaneous course of adhesive capsulitis and leads to good functional results in primary and secondary stiff shoulders.     

Botulinumtoxin-A-Injektion bei therapierefraktärer Giggle-Inkontinenz

A 20-year-old woman reported about giggle incontinence despite antimuscarinic therapy. Therefore we injected botulinum toxin A into the detrusor muscle. The effect of botulinum toxin A appeared about 1 week after injection and no more leakage was observed even during vigorous laughter. A control uroflowmetry showed a good voiding rate without any residual volume. Botulinum toxin A might be an alternative for patients with giggle incontinence after unsuccessful antimuscarinic treatment.     

Laserbehandlung bei nicht-parasitärer Chylurie

Nonparasitic chyluria is rare. Spontaneous remission occurs in 50% of patients. Conservative treatment includes diet with medium-chain triglycerides, lymphangiography, and the instillation of sclerosing solutions of silver nitrate. If conservative management fails, open or retroperitoneoscopic nephrolysis is the treatment of choice. We present a case of spontaneous recumbent nonparasitic chyluria from the left kidney treated twice by endoscopic application of neodymium-YAG laser. This is new to the literature. The chyluria disappeared for several months. The temporary cessation of chyle flow after local laser application should encourage further use of this treatment modality after failure of conservative treatment.     

Molekulargenetische Analyse und klinische Aspekte bei Patienten mit hereditärer Hämochromatose

Background

The purpose of the study was to perform a molecular genetic analysis and to document clinical aspects in patients with hereditary hemochromatosis.

Patients and methods

The study included 33 outpatients (23 males average age 50.6 years and 10 females average age 60.6 years) with a disorder of iron metabolism (transferrin saturation >?75?%) as confirmation of hemochromatosis who were subjected to molecular genetic and clinical analyses.

Results

A homozygous mutation of the hemochromatosis (HFE) gene (C282YY) was detected in 63.6?%, a compound heterozygous mutation (C282Y/H63D) in 30.3% and no mutation of the HFE gene was detected in 6.1?%. The following organ manifestations could be objectified: arthralgia (78.8?%), liver disease (39.9?%), skin hyperpigmentation (30.3?%), osteoporosis (24.2?%), diabetes mellitus (24.2?%) and cardiomyopathy (12.1?%). Comparison between patients with heterozygous and homozygous hemochromatosis revealed the following differences: compound heterozygote patients presented less frequently with osteoarthritis of the metacarpophalangeal (MCP) joints and hands (85.7?%/71.4?% homozygotes vs. 60?%/60?% heterozygotes). Osteoarthritis of the shoulder joints and osteoporosis as well as hypothyroidism were more frequent in compound heterozygote patients, whereas osteoarthritis of the knee and hip joints as well as liver disease were more common in homozygote patients. No differences between both groups were seen with respect to the clinical manifestations of cardiomyopathy and diabetes mellitus.

Conclusion

Prevalent causes of death in hereditary hemochromatosis are heart failure, liver disease (cirrhosis and hepatocellular carcinoma) and portal hypertension. Therefore, an early diagnosis, adequate therapy and genetic screening of family members are of great importance. Medicinal treatment will only effectively prevent deleterious organ involvement and subsequent complications if initiated at an early stage. Furthermore, an overview of the current data is given.     

Endovaskulärer Aortenklappen- und Aszendensersatz

Currently there is no standard endovascular treatment option for ascending aortic aneurysms or dissection combined with aortic valve malformations. Our aim was to design a composite endovascular device consisting of a transcatheter aortic valve prosthesis and integrated thoracic aortic stent graft. The endovascular composite valve graft design is based on five integrated concepts: 1) individualization of prosthesis size according to the anatomy, 2) intraoperative coupling of both components, 3) free diastolic coronary perfusion, 4) distribution of the radial force to three anatomical structures, namely the aortic valve annulus (zone  A), the sinotubular junction (zone B) and the distal ascending aorta (zone C) and 5) single stage implantation. The short distance between the coronary arteries and zone B and significant angulation between the planes of zones B and C must be considered in the composite valve graft designing process. The novel conduit device will enable simultaneous endovascular repair of aortic valve malformations and ascending aorta aneurysms or dissection.     

Testikulärer Keimzelltumor und Sarkoidose

Several case reports and small case series have described a total of 66 patients with sarcoidosis and testicular cancer so far. This report describes three additional cases. We highlight the association of sarcoidosis and testicular cancer and comment on the potential impact of this connection on the interpretation of the radiological and pathological findings in suspected cancer relapse. Sarcoidosis, a condition that can be combined with testicular cancer, should always be considered in the differential diagnosis.     

Behandlungsergebnisse nach primärer und sekundärer Radiusköpfchenresektion

Apart from comminuted fractures of the radial head the indication for resection of the radial head is discussed controversially. To evaluate our own results, the hospital notes of 113 patients treated between 1.1.1984-31.12.1994 in our clinic by posttraumatic primary or secondary radial head resection were examined retrospectively. 79 patients were controlled by clinical and radiological examination with an average follow-up of 37.8 months. We examined at 46 patients the influence of additional lesions of the elbow joint on the functional outcome. In 33 patients follow up was done with special regard to the time of resection. Poor results due to the score from Radian and Riseborough especially followed secondary radial head resection (> 14 days after trauma) and in case of additional elbow lesions. We could not observe problems of the wrist joint after radial head resection as described by other authors. According to our own experience primary resection is recommended in case of doubtful reconstruction of the radial head. In these fracture types radial head resection should not be seen as an alternative treatment because of the worse results following secondary resection.     

Perkutane Mitralklappenintervention bei sekundärer Mitralklappeninsuffizienz

In this case report the complexity of secondary mitral regurgitation, the indications for catheter-based edge-to-edge mitral valve repair using the MitraClip® system and the successful treatment using the heart team approach are presented. Percutaneous edge-to-edge mitral valve repair provides an extension of therapeutic options for patients facing a very high operative risk. Appropriate infrastructure and intensive interdisciplinary cooperation are prerequisites.     

Anästhesiologisches Management bei endovaskulärer Schlaganfalltherapie

Die Anaesthesiologie - Bei akutem ischämischem Schlaganfall (AIS) bewahrt nur die rasche Rekanalisation der verschlossenen Hirnarterie den betroffenen Patienten vor einem schweren...     

EKG-Veränderungen beim Bronchialcarcinom

Ohne ZusammenfassungMit 5 TextabbildungenHerrn Prof. Dr. Dr. h. c.K. H. Bauer zum 70. Geburtstag.